Information Collection

Pregnant Women Eligibility Questionnaire

IC 223887 under ICR 201610-0920-001 · OMB 0920-1142.

Documents and Forms

Document Name Document Type
Pregnant Women Eligibility Questionnaire Form
Pregnant Woman Eligibility Screening Form Att_B1_Pregnant Woman Eligibility Screening Form 09222016.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pregnant Women Eligibility Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NA	Pregnant Woman Eligibility Screening Form	Att_B1_Pregnant Woman Eligibility Screening Form 09222016.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,250	6,250
Annual IC Time Burden (Hours)	521	521
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.